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STROKESTROKE
Provena Regional EMS SystemProvena Regional EMS SystemJanuary 2010January 2010
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³Grandpa had a stroke´³Grandpa had a stroke´
Not too long ago this statement meantNot too long ago this statement meantdeath or disastrous disability for patientsdeath or disastrous disability for patients
and families.and families. In the 21In the 21stst century medical science hascentury medical science has
progressed in the understanding of progressed in the understanding of STROKE, preventionSTROKE, prevention
and treatmentand treatment
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How big is the problem of How big is the problem of STROKE?STROKE?
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Magnitude of the ProblemMagnitude of the Problem
500,000 Americans annually suffer a500,000 Americans annually suffer aSTROKESTROKE
25% die25% die #3 killer of women#3 killer of women
25% of women have strokes before age25% of women have strokes before age
6565 #1 cause of long term disability#1 cause of long term disability
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Stroke in the USStroke in the US
One case of stroke every 45 secondsOne case of stroke every 45 seconds
Results in devastating disabilityResults in devastating disability
16% institutionalized in nursing homes16% institutionalized in nursing homes 31% assistance with ADL (bathing, dressing31% assistance with ADL (bathing, dressing
eating)eating)
20% assistance with walking20% assistance with walking
30% depressed30% depressed
Annual cost of $43 billion Annual cost of $43 billion
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New AdvancementsNew Advancements
The FDA has approved the same clotThe FDA has approved the same clotbusting drugs (tPA thrombolytic) used inbusting drugs (tPA thrombolytic) used inheart attacks to be used in brain attacksheart attacks to be used in brain attacks ± ±
stroke.stroke. Only 2% of stroke victims are treated withOnly 2% of stroke victims are treated with
thrombolytic medicationthrombolytic medication
Aggressive treatment begins with Aggressive treatment begins withassessment and intervention at point of assessment and intervention at point of patient contactpatient contact
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Before STROKE can beBefore STROKE can be
managedmanaged Learn more about what strokes are andLearn more about what strokes are and
how they happen.how they happen.
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A very selfish organ A very selfish organ
The brain requiresThe brain requires
20 % of 20 % of
the total bloodthe total blood
pumpedpumped
by the heart.by the heart.
No fat for storageNo fat for storage
in the brainin the brain Requires constantRequires constant
supply of oxygen and glucose.supply of oxygen and glucose.
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Blood Supply to the BrainBlood Supply to the Brain
Carotid arteriesCarotid arteries ± ± anterior neckanterior neck
Vertebral arteriesVertebral arteries ± ± through cervicalthrough cervical
vertebraevertebrae
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Circle of WillisCircle of Willis
Both blood supplies join on the under Both blood supplies join on the under surface of the brain.surface of the brain.
FailFail--safe mechanismsafe mechanismin case of a blockagein case of a blockage
somewhere insomewhere in
circulationcirculation
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What can go wrong???What can go wrong???
Disruption of blood flow to the brainDisruption of blood flow to the brain
PlaquePlaque
Foreign debrisForeign debris Broken vesselBroken vessel
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Ischemic STROKEIschemic STROKE
Progressive ThrombusProgressive Thrombus
Plaque depositPlaque deposit ± ± similar to process in heart withsimilar to process in heart withcoronary artery diseasecoronary artery disease
Cerebral EmboliCerebral Emboli ----Clot from somewhere elseClot from somewhere else ----floating debrisfloating debris
Blood clotBlood clot
Air bubble Air bubble
Bubble of amniotic fluidBubble of amniotic fluid
Bone marrow fromBone marrow from
a fracturea fracture
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HemorrhagicHemorrhagic STROKESTROKE
Aneurysm Aneurysm ± ± weakened area in arteryweakened area in artery
CongenitalCongenital
Younger population younger than 40 yearsYounger population younger than 40 years ³worst headache in my life´³worst headache in my life´
Spontaneous Hypertensive BleedSpontaneous Hypertensive Bleed
BP 200/100BP 200/100
Malformed ArteryMalformed Artery
50% younger than 30 years50% younger than 30 years
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Transient Ischemic AttackTransient Ischemic Attack
³One Free Spin´³One Free Spin´
Looks like a stroke but,symptoms improve inLooks like a stroke but,symptoms improve in11--24 hours24 hours
Temporary disruption of blood flow to theTemporary disruption of blood flow to thebrainbrain ----Angina of the brain Angina of the brain
Warning signWarning sign
Mimicked by low blood sugar Mimicked by low blood sugar 30% of patients will have a true stroke in 3030% of patients will have a true stroke in 30
daysdays
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Can STROKES be prevented?Can STROKES be prevented?
Modifiable risk factorsModifiable risk factors
High BPHigh BP
Cigarette smokingCigarette smoking Alcohol intake Alcohol intake
Uncontrolled Heart diseaseUncontrolled Heart disease
Atrial fibrillation Atrial fibrillation
Uncontrolled DiabetesUncontrolled Diabetes
Carotid congestionCarotid congestion
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High blood cholesterolHigh blood cholesterol
Sedentary lifestyleSedentary lifestyle
ObesityObesity SeasonsSeasons
StressStress
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Risk Factors Unable to ControlRisk Factors Unable to Control
Age Age
Gender Gender
RaceRace Prior strokesPrior strokes
HeredityHeredity
Sickle Cell DiseaseSickle Cell Disease
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Signs and Symptoms of Signs and Symptoms of
STROKESTROKE HemorrhagicHemorrhagic
Sudden and dramaticSudden and dramatic
Violent explosive headacheViolent explosive headache Visual disturbanceVisual disturbance
Nausea and vomitingNausea and vomiting
Neck and back painNeck and back pain
Sensitivity to lightSensitivity to light
Weakness on one sideWeakness on one side
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Signs and Symptoms of Signs and Symptoms of
STROKESTROKE Ischemic StrokeIschemic Stroke
Harder to detectHarder to detect
Weakness in one sideWeakness in one side Facial droopingFacial drooping
Numbness and tinglingNumbness and tingling
Language disturbanceLanguage disturbance
Visual disturbanceVisual disturbance
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Left Brain DamageLeft Brain Damage
Right side paralysisRight side paralysis
Speech and language disturbanceSpeech and language disturbance
Behavioral changesBehavioral changes Swallowing problemsSwallowing problems
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Right Brain DamageRight Brain Damage
Left side paralysisLeft side paralysis
Spatial perceptionSpatial perception
CoordinationCoordination PerceptionPerception
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Primary Stroke CarePrimary Stroke Care
180 minute window of time180 minute window of time Time is tissueTime is tissue
The longer the brain is withoutThe longer the brain is without
oxygen and glucose the moreoxygen and glucose the morebrain cells diebrain cells die
Goal is to restore blood flow asGoal is to restore blood flow as
soon as possiblesoon as possible
Treatment is a system beginning with EMS andTreatment is a system beginning with EMS andcontinuing through CCUcontinuing through CCU
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Goals of Primary STROKE CareGoals of Primary STROKE Care
Rapid Recognition of STROKE SymptomsRapid Recognition of STROKE Symptoms
Rapid access in to the systemRapid access in to the system
Assessment Assessment TreatmentTreatment
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Seven D¶s of STROKE CareSeven D¶s of STROKE Care
DetectionDetection ± ±of STROKE symptomsof STROKE symptoms
DispatchDispatch± ± of EMSof EMS
DeliveryDelivery ± ± to a facility prepared to manage STROKEto a facility prepared to manage STROKE
Door to treatmentDoor to treatment± ± rapid diagnosis and decisionrapid diagnosis and decisionmakingmaking
DataData± ± CT ScanCT Scan
DecisionDecision± ± Ischemic or Hemorrhagic, does the patientIschemic or Hemorrhagic, does the patientmeet the criteriameet the criteria
DrugDrug ± ± thrombolytics when appropriatethrombolytics when appropriate
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EMS Has a Critical RoleEMS Has a Critical Role
Educate your communityEducate your community
At first signs of a possible STROKE call At first signs of a possible STROKE call
EMSEMS ³³Don¶t guess call EMS!!´ Don¶t guess call EMS!!´
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Use a ³Use a ³FAST FAST ́ STROKE´ STROKE
Assessment Assessment Modification of Cincinnati PreModification of Cincinnati Pre--HospitalHospitalStroke ScreenStroke Screen
FaceFace Arm Arm
SpeechSpeechTime of onsetTime of onset
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FACEFACE
Look for Facial DroopLook for Facial Droop
Have the patient smile or show his/her teethHave the patient smile or show his/her teeth
NORMALNORMALB
oth sides of theB
oth sides of theface move equallyface move equally
ABNORMAL ABNORMAL One side of One side of
the patient¶s face droopsthe patient¶s face droops
or does not moveor does not move
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ARMS ARMS
Motor Weakness: Look for arm drift by askingMotor Weakness: Look for arm drift by askingthe patient to close eyes and lift arms, palms upthe patient to close eyes and lift arms, palms up
NORMALNORMAL-- arms remainarms remain
extended equally or driftextended equally or drift
downward equallydownward equally
ABNORMAL ABNORMAL ± ± One armOne arm
drifts down compareddrifts down comparedto the other to the other
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SPEECHSPEECH
Ask the patient to say Ask the patient to say ³Y ou can¶t teach an³Y ou can¶t teach an
old dog new tricks´ old dog new tricks´
NORMALNORMAL ± ±Phrase repeated clearly andPhrase repeated clearly andplainlyplainly
ABNORMAL ABNORMAL ± ± Words slurred, abnormal or Words slurred, abnormal or unable to speakunable to speak
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Abnormal Speech Abnormal Speech
Slurring of speechSlurring of speech
Unable to think of wordsUnable to think of words
Inappropriate wordsInappropriate words Expressive aphasiaExpressive aphasia ± ± unable to speakunable to speak
wordswords
Receptive aphasiaReceptive aphasia ± ± unable to understandunable to understandwordswords
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TIME OF ONSETTIME OF ONSET
The window of opportunity to effectivelyThe window of opportunity to effectivelytreat STROKE is 3 hours (180 minutes)treat STROKE is 3 hours (180 minutes)
May be extended to 4 ½ hoursMay be extended to 4 ½ hours
Need to know ³ last known well´.Need to know ³ last known well´.
Difficult whenDifficult when
Patient lives alonePatient lives alone
Woke up with symptomsWoke up with symptoms
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Assessing the Stroke Patient Assessing the Stroke Patient
Initial AssessmentInitial Assessment
General ImpressionGeneral Impression
Airway Airway Airway!!Airway Airway Airway!!
HighHigh--flow O2flow O2
CirculationCirculation HIGH PRIORITY! For transportHIGH PRIORITY! For transport
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Focused history and physical examFocused history and physical exam Perform thorough neurologic exam.Perform thorough neurologic exam.
Cincinnati PreCincinnati Pre--hospital Stroke Screenhospital Stroke Screen
GlasgowComa ScaleGlasgowComa Scale
History of History of
SeizuresSeizures
HeadacheHeadache
Nausea/vomitingNausea/vomiting
Neck painNeck pain
GetGet DETAILEDDETAILED OPQRST and SAMPLEOPQRST and SAMPLE
Obtain baseline set of vitalsObtain baseline set of vitals
Recheck Vital Signs frequentlyRecheck Vital Signs frequently
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PrePre--hospital priorities of carehospital priorities of care
Conduct general medical assessmentConduct general medical assessment TraumaTrauma ± ± recent or within last monthrecent or within last month
Recent seizureRecent seizure
Could be a subdural hematomaCould be a subdural hematoma
Cardiovascular Cardiovascular ± ± on heart medicationson heart medications Does the patient have atrial fibrillationDoes the patient have atrial fibrillation
Does the patient take blood thinnersDoes the patient take blood thinners
Pulse oximetry > 94%Pulse oximetry > 94%
Blood sugar treat if ableBlood sugar treat if able Low blood sugars mimic a strokeLow blood sugars mimic a stroke
PupilsPupils
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PositionPosition
Protect potentially paralyzed partsProtect potentially paralyzed parts
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EMS Packaging Check ListEMS Packaging Check List
Stroke identificationStroke identification
Use of FAST ScreenUse of FAST Screen
Securing A B CsSecuring A B Cs
EKG
monitoring if ableEKG
monitoring if able Oxygen saturation of > 94%Oxygen saturation of > 94%
Management of blood glucoseManagement of blood glucose
IV access if ableIV access if able
Blood specimens obtained if ableBlood specimens obtained if able
Head of Bed elevated 15 degreesHead of Bed elevated 15 degrees
Early communication with EDEarly communication with ED
Urgent transportUrgent transport
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Could this be anything other Could this be anything other
than a STROKE?than a STROKE?
Transient Ischemic AttackTransient Ischemic Attack
HypoglycemiaHypoglycemia
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Goals of STROKE Care 2010Goals of STROKE Care 2010
Standardized assessments, vocabulary,Standardized assessments, vocabulary,protocols and goalsprotocols and goals
Door to treatment goal in ED is 60 minutesDoor to treatment goal in ED is 60 minutes Early EMS identification of candidates andEarly EMS identification of candidates and
packagingpackaging
Direct transport from preDirect transport from pre--hospital to CThospital to CTscan through EDscan through ED
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Putting a Patient Through thePutting a Patient Through the
ProcessProcess EMS is dispatchedEMS is dispatched
EMS Initial Assessment using FAST ScreenEMS Initial Assessment using FAST Screen
ED notified by EMS EARLYED notified by EMS EARLY
Paramedic draws labsParamedic draws labs
CT scan notified by EDCT scan notified by ED
Pharmacy notified by EDPharmacy notified by ED
EMS briefly stops at registration to get labels for EMS briefly stops at registration to get labels for lab tubeslab tubes
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EMS stops briefly in ED for physicianEMS stops briefly in ED for physicianassessmentassessment
EMS and ED nurse take patient directly toEMS and ED nurse take patient directly toCT scan and place the patient on the tableCT scan and place the patient on the table
ED physician talks with familyED physician talks with family
ED RN validates assessment and historyED RN validates assessment and historyusing NIH Stroke Scaleusing NIH Stroke Scale
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ED RN evaluates and treats BPED RN evaluates and treats BP
Radiologist reads CT scan and sendsRadiologist reads CT scan and sends
report to EDreport to ED ED physician makes decision regardingED physician makes decision regarding
treatment with thrombolyticstreatment with thrombolytics
ED calls pharmacy and requests tPAED calls pharmacy and requests tPA
ED RN administers tPAED RN administers tPA
Admission to CCU Admission to CCU
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NINDS Recommended GoalsNINDS Recommended Goals
Door to doctor Door to doctor 10 minutes10 minutes
Door to CT completionDoor to CT completion 25 minutes25 minutes
Door to CT readDoor to CT read 45 minutes45 minutes
Door to treatmentDoor to treatment 60 minutes60 minutes Access to neurological expertise* Access to neurological expertise* 15 minutes15 minutes
Access to neuro Access to neuro--surgical expertise*surgical expertise* 120 minutes120 minutes
Admit to monitored bed Admit to monitored bed 180 minutes180 minutes
* by phone or in person* by phone or in person
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Case Study 1: 6:30 pmCase Study 1: 6:30 pm
ALS ambulance is dispatched to a ALS ambulance is dispatched to ashopping mall for a collapsed female.shopping mall for a collapsed female.
W hat could be the problem?W hat could be the problem?
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What could be the problem?What could be the problem?
SeizureSeizure
CodeCode
Myocardial infarctionMyocardial infarction
Diabetic reactionDiabetic reaction
Over doseOver dose
Anxiety attack Anxiety attack
TraumaTrauma
STROKESTROKE
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6:35 pm6:35 pm
Upon arrival, you find an AfricanUpon arrival, you find an African--American Americanwoman sitting on a bench. She iswoman sitting on a bench. She isconfused, but responds to verbal stimuli.confused, but responds to verbal stimuli.
W hat assessments do you need?W hat assessments do you need?
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Airway and ventilations are adequate Airway and ventilations are adequate
Regular pulse and good perfusionRegular pulse and good perfusion
Speech is garbledSpeech is garbled Unable to move her right arm and legUnable to move her right arm and leg
Denies chest pain.Denies chest pain.
BP 195/105, pulse 90, respirations 18BP 195/105, pulse 90, respirations 18
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The patient¶s daughter reports that her mother The patient¶s daughter reports that her mother felt fine while shopping, when suddenly her armfelt fine while shopping, when suddenly her armfelt funny. She sat down on the bench, and didfelt funny. She sat down on the bench, and did
not fall or hit her head. She did not losenot fall or hit her head. She did not loseconsciousness and did not have a seizure.consciousness and did not have a seizure.
The woman did not complain of a headache,The woman did not complain of a headache,and has no history of seizures, diabetes, chestand has no history of seizures, diabetes, chestpain or palpitations.pain or palpitations.
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6:43 pm6:43 pm
This patient, Mrs. Short, is 65 years old.This patient, Mrs. Short, is 65 years old.She has left sided facial drooping and rightShe has left sided facial drooping and rightarm and leg weakness. She can move thearm and leg weakness. She can move theright arm and leg slightly, but with greatright arm and leg slightly, but with greatdifficulty. Her speech is slurred. All of difficulty. Her speech is slurred. All of these signs and symptoms are new in thethese signs and symptoms are new in the
last half hour.last half hour.
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FASTFAST
How does Mrs. Short fare on the FASTHow does Mrs. Short fare on the FASTScreen?Screen?
FaceFace
Arm Arm
SpeechSpeech
TimeTime
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Case 1 contCase 1 cont
FaceFace ---- left sided facial droopingleft sided facial drooping
Arm Arm ± ± right arm and leg weaknessright arm and leg weakness
SpeechSpeech ± ± speech is slurredspeech is slurred Time last known wellTime last known well ---- unsureunsure
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HIGH PRIORITYHIGH PRIORITY
Determine precise time of onset of signsDetermine precise time of onset of signsand symptoms.and symptoms.
If thrombolytic therapy is to be considered,If thrombolytic therapy is to be considered,itsits infusioninfusion must begin within 3 hours of must begin within 3 hours of the onset of symptoms.the onset of symptoms.
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Elicit cues to determine exactElicit cues to determine exactonsetonset
The daughter remembers that she and her The daughter remembers that she and her mother were walking past the electronicsmother were walking past the electronicsstore and stopped to watch the weather onstore and stopped to watch the weather on
the local news program. The weather isthe local news program. The weather isalways on at 6:20. The symptoms beganalways on at 6:20. The symptoms beganwhen they stopped.when they stopped.
The 180 minute clock started at 6:20 pm.The 180 minute clock started at 6:20 pm.
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Provide preProvide pre--arrival notification to receivingarrival notification to receivinghospital of potential stroke patient.hospital of potential stroke patient.
Rapid transport to an appropriate facility.Rapid transport to an appropriate facility.
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6:50 pm6:50 pm
Enroute vital signs are:Enroute vital signs are:
BP 198/120BP 198/120
Pulse 92Pulse 92
Respirations 22Respirations 22
Do you want to treat the blood pressure at thisDo you want to treat the blood pressure at this
time?time?
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Do not treat the high blood pressure. ItDo not treat the high blood pressure. Itmay be the only perfusion for her may be the only perfusion for her distressed brain.distressed brain.
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Does Mrs. Short meet the criteria so far toDoes Mrs. Short meet the criteria so far tobe on the Primary STROKE Care track tobe on the Primary STROKE Care track toreceive thrombolytics (tPA)?receive thrombolytics (tPA)?
YES, Proceed to a hospital ready toYES, Proceed to a hospital ready tomanage an acute STROKEmanage an acute STROKE
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Case Study 2: 0635 HoursCase Study 2: 0635 Hours
70 year 70 year--old woman, Mrs. Blackold woman, Mrs. Black
Awake with slight weakness and tingling Awake with slight weakness and tinglingin her left side.in her left side.
Speech is hesitant and slightly slurredSpeech is hesitant and slightly slurred
Vision seems to be normalVision seems to be normal
No facial droopingNo facial drooping Good eye contactGood eye contact
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Case 2 cont.Case 2 cont.
Symptoms began 0530 per husbandSymptoms began 0530 per husband
Speech was fine before thatSpeech was fine before that
Blood sugar 50 mg/dlBlood sugar 50 mg/dl
No emesis or seizureNo emesis or seizure
BP 150/90, Pulse 80, Respirations 16BP 150/90, Pulse 80, Respirations 16
O2 sat 92%O2 sat 92%
Weighs 140 poundsWeighs 140 pounds
No aspirin intakeNo aspirin intake
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FASTFAST
How does Mrs. Black fareHow does Mrs. Black fare
on the FAST Screen?on the FAST Screen?
FaceFace Arm Arm
SpeechSpeech
TimeTime
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Case 2 contCase 2 cont
FaceFace ---- no droopingno drooping
Arm Arm ± ± slight weakness and tinglingslight weakness and tingling
SpeechSpeech ---- Speech is hesitant and slightlySpeech is hesitant and slightlyslurredslurred
Time known wellTime known well ---- 65 minutes ago65 minutes ago
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Case Study 3Case Study 3
1400 hours1400 hours
80 year 80 year--old man, Mr. Schmidtold man, Mr. Schmidt
Daughter found him 15 minutes agoDaughter found him 15 minutes ago
Unknown down timeUnknown down time
Awake Awake
Drooping left side of faceDrooping left side of face
No movement of right arm and legNo movement of right arm and leg
Speech too slurred to understandSpeech too slurred to understand
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Case 3 cont.Case 3 cont.
Seems to see youSeems to see you
Looks only to leftLooks only to left
Blood sugar 200 mg/dlBlood sugar 200 mg/dl No evidence of seizure or emesisNo evidence of seizure or emesis
BP 180/100, pulse 72, respirations 15BP 180/100, pulse 72, respirations 15
Unsure of aspirinUnsure of aspirin
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FASTFAST
How does Mr. Schmidt fareHow does Mr. Schmidt fare
on the FAST Screen?on the FAST Screen?
FaceFace Arm Arm
SpeechSpeech
TimeTime
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Case 3 contCase 3 cont
FaceFace ----Drooping left side of faceDrooping left side of face
Arm Arm ± ± No movement of right arm and legNo movement of right arm and leg
SpeechSpeech ± ± Speech too slurred toSpeech too slurred tounderstandunderstand
Time known wellTime known well ± ± unknown, daughter unknown, daughter
found him 15 minutes ago, but she had notfound him 15 minutes ago, but she had nothad contact with him since yesterdayhad contact with him since yesterday
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Case 3 Cont.Case 3 Cont.
Time of onset = unknownTime of onset = unknown
Severe Headache = unknownSevere Headache = unknown
Emesis = noEmesis = no ASA = unknown ASA = unknown
Seizures = noSeizures = no
Consenting party = yesConsenting party = yes Blood sugar = OKBlood sugar = OK
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Case 3Case 3
Time window has closed. Not a candidateTime window has closed. Not a candidatefor thrombolytic treatment. Transport tofor thrombolytic treatment. Transport toED for acute care.ED for acute care.
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QuizQuiz
What are the 2 general types of stroke?What are the 2 general types of stroke? 1.1.
2.2.
What condition is equivalent to ³angina´ of theWhat condition is equivalent to ³angina´ of thebrain?brain? 3.3.
What are 3 risk factors for stroke that can beWhat are 3 risk factors for stroke that can bemodified?modified? 4.4.
5.5.
6.6.
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What are 2 risk factors for stroke that cannot beWhat are 2 risk factors for stroke that cannot bemodified?modified?
7.7.
8.8. What are you measuring in a FAST StrokeWhat are you measuring in a FAST Stroke
Screen?Screen?
9.9.
10.10.
11.11.
12.12.
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In the 21In the 21stst century, some patients sufferingcentury, some patients sufferingfrom STROKE can be treated using whatfrom STROKE can be treated using whattype of medication?type of medication?
13.13.
What is the time deadline that must be metWhat is the time deadline that must be metin order to use the aggressive medicationin order to use the aggressive medication
in the question above?in the question above? 14.14.
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How can EMS make a difference in earlyHow can EMS make a difference in earlyrecognition of STROKE in their recognition of STROKE in their community?community?
15.15.
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Answers Answers
1. Hemorrhagic stroke1. Hemorrhagic stroke
2. Ischemic stroke2. Ischemic stroke
3. TIA (transient ischemic attack)3. TIA (transient ischemic attack)
4.4. ± ± 6.6. High BPHigh BP
Cigarette smokingCigarette smoking High blood cholesterolHigh blood cholesterol
Sedentary lifestyleSedentary lifestyle Carotid CongestionCarotid Congestion
ObesityObesity Uncontrolled diabetesUncontrolled diabetes
SeasonsSeasons Atrial fibrillation Atrial fibrillation StressStress Uncontrolled heart diseaseUncontrolled heart disease
Alcohol intake Alcohol intake
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77--88 Age Age prior strokesprior strokes
Gender Gender heredityheredity
RaceRace Sickle cell diseaseSickle cell disease
9. Face9. Face
10. Arm10. Arm
11. Speech11. Speech
12. Last known well12. Last known well
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